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About NW-SCC

Adult Education Enrollment Form

*Required Fields

Please use your full legal name. (No nicknames)





Do you prefer day or night class?


DEMOGRAPHICS

Ethnicity
Language
Gender
Citizenship


EDUCATION

Highest level of schooling or degree attained:
Education Type


EMPLOYMENT

Are you employed?


MISCELLANEOUS

Miscellaneous - Select all that apply:


REFERRAL SOURCE

I learned about the AE class from:


LEARNER REQUEST FOR SUPPORT NEEDS

Learning Needs
Support Needs


DATA EXCHANGE PERMISSION

Applicant hereby provides permission for his/her data to be exchanged with other education and workforce agencies for the purpose of verifying outcomes, performance, and credentials related to postsecondary education/training and employment or other services that are provided by Adult Education.

If I am a recipient of SNAP (formerly known as the Food Stamp program), I am aware that participation in the A-RESET program is voluntary and will not affect my SNAP benefits, but full participation may increase my chances of finding employment of getting a better job.

Data Exchange Permission


Please skip the section below on Primary and Secondary Designation. 

It will be completed by Adult Education Staff when your enrollment form is processed.

Primary Designation (ABE / ASE or ESL)
Secondary Designation (WorkKeys)